Facet Blockade

Patients presenting with isolated back pain and spinal stenosis often have an element of facet arthropathy contributing to their pain. Facet blocks are performed under fluoroscopic guidance, and can be either intaarticular injections, or medial branch blocks. The medial branch of the dorsal ramus supplies sensory innervation to the facet joint. Blockade of this nerve has been shown to be as effective as intraarticular infiltration. It is perfomed quicker and easier, and is more comfortable for the patient. Also, it serves as a diagnostic block for potential radiofrequency lesioning of the medial branch if the block does not afford long term relief. The procedure is performed with the patient in the prone position. The medial transverse processes are identified under fluoroscopy, and a 22 gauge spinal needle is placed at the superior and lateral junction of the transverse process and the pedicle of each lumbar vertrebrae. A solution of 1 cc of 0.25% Bupivicaine and 20 mg of methylprednisolone is then infiltrated after negative aspiration at each level. Typically, three to four levels are blocked, and unilateral or bilateral depending on the patients symptoms. Initial relief of symptoms is reported in 54% to 65% of patients, with relief of greater than 6 months in up to 30% of patients.

Cervical facet arthropathy is also frequently seen in a pain mangement practice, and a similar procedure can be performed for the neck as for the low back. The cervical procedure is somewhat more challenging, as the density of the cervical bony elements is lower than in the lumbar region, and is visualized poorly. In addition, there is evidence that vestibular input from the neck is important in maintaining equilibrium. Blockade of both sides at one session can make some patients very dizzy, so only one side is typically performed at a time

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